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The ABCs of CBT for Insomnia:

A Brief Review of Cognitive-Behavioral

Interventions for the Treatment of Insomnia
Michael Schmitz, PsyD, LP, CBSM
Behavioral Sleep Medicine Program
Abbott Northwestern Sleep Center

Goals of Presentation

Provide a brief overview of normal sleep

Describe insomnia, prevalence, and impact
Explain model of development of insomnia that
serves as basis for cognitive-behavioral therapy for
insomnia (CBT-I)
Describe major elements of CBT-I

What is normal sleep

Total sleep need varies from one person to the

Most of us need between 7-9 hours of sleep
per night.
Normal sleep should make us feel relatively
As we age our sleep becomes lighter.

Ascending Reticular Activating

system promotes and maintains
wakefulness via excitatory activities
of certain neurotransmitters.

gamma aminobutyric
acid GABA) from brain
stem and basal
forebrain inhibits
activating system
resulting in sleep

Sleep States, Stages and Cycles

2 Sleep States:

REM and Non-REM

4 Sleep Stages:

Stage N1. N2, N3 and


4-6 Sleep Cycles per night:

Each 90-120 minutes

Normal sleep in young adult

REM Stage



Hours of Sleep

Adapted from Berger RJ. The sleep and dream cycle. In: Kales A, ed. Sleep
Physiology & Pathology: A Symposium. Philadelphia: J.B. Lippincott; 1969.

Why we feel Sleepy? Two Processes

Two processes combined determine sleep

propensity and the duration of sleep

Homeostatic sleep drive:

Process driven by amount of time awake

Linear and cumulativeone gets progressively more tired
with each passing hour (sleep load increases)

Circadian rhythm:

Process driven by biological clock (time of day)

Cyclicalperiods of sleepiness occur at roughly the same
times each day

Combined Sleep Processes

The physiological
pressure to sleep
progresses linearly




pressure to





Time (48 hours)



University of Virginia Center for Biological Timing.

Available at:

What is Insomnia?

Complaint of inadequate or insufficient sleep

Difficulty initiating sleep (30+ minutes to fall asleep)
Frequent awakenings from sleep (multiple & lengthy)
Short sleep time
Complaint of non-restorative sleep
1 month or greater duration
Complaint of daytime consequences such as fatigue or
impairment in social, occupational or other areas of

Classification of insomnia

Primary Insomnia - complaint not thought

to be due to effects of another psychiatric
condition, medical factor, medication, or sleep

Psychophysiologic insomnia
Sleep state misperception (paradoxical insomnia)
Idiopathic insomnia
12-15% of patients seeking treatment at sleep
disorder centers

Classification of insomnia

Secondary insomnia

Presumed to be the direct consequence of another


Psychiatric condition
Medical condition
Other sleep disorder
Situational or other extrinsic factors

Problems with classification

Treatment or resolution of primary condition

presumed to cause secondary insomnia does not
reliably cure insomnia
CBT (Cognitive Behavioral Treatment) for
insomnia, once thought to be effective only in
Primary Insomnia, is proving to be clinically
effective in individuals with comorbid conditions.
Secondary insomnia Comorbid insomnia

Insomnia and Hyperarousal

Insomnia considered by
many to be, at least in
part, a disorder of

Increased heart rate

Faster brain wave activity
Higher core body temperature
Elevated cortisol levels

Impact of Insomnia

40-70 million Americans affected by intermittent or chronic


Chronic Insomnia estimated to be between 9-12%

5-25% of persons with insomnia seek treatment

75% of insomnia is treated by primary physicians

Increased health care utilization

Increased work absenteeism

Predictor of depression

Impact of Insomnia

Whos at risk?

Medical and Psychiatric Patients

Shift Workers


Older individuals

Four Factor Model of Insomnia

Predisposing factors

Precipitating factors

life stress

Perpetuating factors

Increased arousal level

Medical and mental health factors

sleep hygiene issues

excessive time in bed
incompatible non-sleep related behavior in bed
cognitive arousal, worry about sleep, sleep effort

Conditioned arousal classical conditioning

Cognitive-Behavioral Treatment of Insomnia

Why CBT for Insomnia?

Most extensive review of chronic insomnia management

(Buscemi, et al. (2005) indicates benefits of benzodiazepines
agonists inflated and offset by potential harm.
Meta-analysis of hypnotic use (Glass, J, et al. (2005)
concludes that modest benefits outweighed by risk of harm in
older adults
Recent studies comparing cognitive-behavioral treatments
with sleep medication show behavioral treatments of equal or
greater effectiveness and with sustained improvement at 12
and 18 months.
Sleeping pills present risk for drug dependent insomnia

Drug dependent insomnia

Hauri, P, 1996

Meta-Analysis of CBT-I Results

Statistical Significance

SOL reduced 65 35 min.

WASO reduced 70 30 min.

Awakenings reduced 2 1

TST increased from 6 to 6.5 hours

Clinical Significance

Subjective rating of improved

sleep quality.

50% improvement in target


SOL and WASO (35) close to

defined cutoff score

Sleep efficiency improved

Reduced hypnotic use

Why Arent Behavioral

Techniques Used more frequently?

Lack of physician awareness

Techniques are time intensive

Difficulty with reimbursement issues

Lack of skilled behavioral clinicians

Limited research on behavioral techniques why they work

and what combination of strategies optimize effectiveness

Types of Cognitive-Behavioral
Therapy for Insomnia

Stimulus control
Sleep restriction
Cognitive therapy
Relaxation training
Sleep hygiene
Multimodal Cognitive-behavioral therapy for
insomnia combines elements of above

The sleep log as key tool for self-monitoring

and treatment

Teaching clients how to keep track

of their sleep

Time it takes you to fall asleep
Nighttime awakenings
Time you are awake during the night after you
fall asleep
Time you got out of bed.
Remind clients that all data is a guesstimate

Stimulus Control Therapy

Assumption: Bed space becomes associated with sleep

incompatible behaviors and experience as individual tries
to decrease physical and cognitive arousal associated with
sleep effort.

Goal: Re-associate bedroom with sleep. May influence

homeostatic and circadian sleep mechanisms.

Findings: Positive results for all sleep parameters.

Considered by the American Academy of sleep medicine
to be the first-line behavioral treatment for chronic

Stimulus Control Therapy

1. Go to bed only when sleepy
2. Use bedroom only for sleep and sex.
3. Get out of bed if awake for more than 15-10
minutes and go to another room..
4. Return to bed when sleepy. Repeat steps 3 and 4
as often as necessary.
5. Maintain consistent wake time
6. Avoid napping

Stimulus Control Treatment


Finding the best wake time.

Method alone does not specifically address
the effect that maladaptive beliefs and
cognitions may have on arousal, anxiety, and
maintenance of wakefulness.
Individuals with mobility and pain issues may
find instructions difficult to follow.

Sleep Restriction Therapy

Assumption: Individual spends excessive time in bed in an

effort to cope with sleep loss and obtain more sleep. This may
affect the homeostatic drive mechanism of sleep

Goal: Promote mild sleep deprivation, increase homeostatic

pressure for sleep

. Findings: Good results for most sleep parameters. Used in

most multiple component CBT therapies

Sleep Restriction Therapy


Cut time in bed (TIB) to amount of time sleeping.

Increase TIB when sleep efficiency is >90% . Sleep

efficiency is ones total sleep time divided by time spent
in bed.

Decrease TIB when sleep efficiency is <85%

Keep hours same with sleep efficiency 85%--90%

Adjust schedule weekly until optimum duration of sleep


Relaxation Therapy

Assumption: High levels of somatic and cognitive

arousal prevent sleep initiation and maintenance.

Goal: Reduce arousal with specific techniques

Findings: Most demonstrate significant improvements in

reducing problems with sleep initiation. May be less
effective than stimulus control

Relaxation Therapy

Somatic Arousal
PMR - tensing and relaxing muscle groups
Biofeedback - audio or visual feedback
Deep Breathing
Cognitive Arousal
Thought Stopping

Sleep Hygiene Instruction

Assumption: Poor sleepers have worse sleep habits than

good sleepers.

Goal: Improve environmental factors and health behaviors

Findings: Limited benefits used alone. Used in conjunction

with other behavioral therapies in most CBT protocols.
Method used most in primary care. Often mistakenly
assumed by health care practitioners to be the core of CBT
for insomnia.

Healthy Sleep Habits

Avoid alcohol, nicotine, caffeine, chocolate

Cut down on non-sleeping time in bed

Bed only for sleep and satisfying sex

Avoid trying to sleep

For 4-6 hours before bedtime

You cant make yourself sleep, but you can set the stage
for sleep to occur naturally

Avoid a visible bedroom clock with a lighted dial

Dont let yourself repeatedly check the time!

Can turn the clock around or put it under the bed

Health Sleep Habits (cont.)

Establish a regular sleep schedule

Establish a relaxing routine before bed

Deal with your worries before bedtime

Get up at the same time 7 days a week

Go to bed at the same time each night
Exercise every day - exercise improves sleep!

Plan for the next day before bedtime

Set a worry time earlier in the evening

Adjust the bedroom environment

Sleep is better in a cool room, around 65 F.

Darker is better

Cognitive therapy

Assumption: Maladaptive thoughts produce stress

and arousal affecting sleep

Goal: Alter faulty beliefs about sleep to reduce

emotional distress.
Identify beliefs about sleep that are incorrect
Challenge their truthfulness
Substitute realistic thoughts

Maladaptive beliefs about sleep

Misconceptions about causes of insomnia

Unrealistic expectations re: sleep needs

I must have 8 hours of sleep each night.

Faulty beliefs about insomnia consequences

Insomnia is a normal part of aging.

Insomnia can make me sick or cause a mental


Misattributions of daytime impairments

Ive had a bad day because of my insomnia.

I cant have a normal day after a sleepless night.

Multi-Component CBT for Insomnia

Assumption: Perpetuating factors and conditioned

arousal increase psychophysiological arousal and
negatively affect intrinsic sleep promoting processes.
Goal: Identify primary factors contributing to
maintenance of insomnia and apply appropriate
cognitive-behavioral components to reduce arousal
and emotional distress about sleep while promote
behaviors that are sleep compatible
Findings: Trend is toward multi-component CBT
for insomnia and compares positively to trials with
several sleep medications.

Individualizing CBT-I

Assess the relative impact of sleep hygiene,

sleep schedule, sleep anxiety (beliefs) and other factors on
Assess motivation for behavior change:
Does the individual expect a quick fix or appreciate improvement in
sleep will take time and effort?
Does he/she view insomnia as in intrinsic disease or
primary as the result of behavioral factors and conditioning?

Appreciate and explore the often multiple and frustrating

efforts to treat insomnia. Discuss how this may serve to
maintain insomnia

Individualizing CBT-I

Provide general information about sleep and sleep hygiene.

Explain developmental model of insomnia, elements of
treatment and efficacy.
Discuss sleep log, self-monitoring.
Explore challenges and barriers to implementing treatment.
Negotiate about specific behavioral change.
Initiate stimulus control, usually combined with sleep
Weave cognitive therapy into course of treatment by having
client identify and challenge unhelpful beliefs about
Relaxation training is usually adjunctive and often combined
with strategies to reduce tension and stress throughout the

Other Considerations

Core body temperature and sleep

Very hot bath (~15-30 min. Duration) 1 1/2 hour before bedtime may
improve ability to maintain sleep, increase SWS
Turn down thermostat, no electric blankets

Effects of light on sleep

Early morning bright light will advance the circadian clock i.e. make
you sleepy earlier
Late afternoon bright light will delay your body clock i.e. make you
sleepy later
Wear dark glasses to minimize light to retina if your body clock is
already shifted
Avoid bright light at night, use incandescent light with the lowest
wattage possible.